In

Invvestigation for injuries to the cervical spine in

children with head injury

NICE Pathways bring together all NICE guidance, quality standards and other NICE
information on a specific topic.

NICE Pathways are interactive and designed to be used online. They are updated
regularly as new NICE guidance is published. To view the latest version of this pathway
see:

http://pathways.nice.org.uk/pathways/head-injury
Pathway last updated: 16 December 2016

This document contains a single pathway diagram and uses numbering to link the
boxes to the associated recommendations.

Copyright © NICE 2016. All rights reserved

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Invvestigation for injuries to the cervical spine in children with head injury NICE Pathways

Head injury path

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Invvestigation for injuries to the cervical spine in children with head injury NICE Pathways

1 Child with head injury

No additional information

2 Risk factors indicating CT cervical spine scan within 1 hour

For children who have sustained a head injury, perform a CT cervical spine scan only if any of
the following apply (because of the increased risk to the thyroid gland from ionising radiation
and the generally lower risk of significant spinal injury):

GCS less than 13 on initial assessment. See recommendations on GCS [See page 6].
The patient has been intubated.
Focal peripheral neurological signs.
Paraesthesia in the upper or lower limbs.
A definitive diagnosis of cervical spine injury is needed urgently (for example, before
surgery).
The patient is having other body areas scanned for head injury or multi-region trauma.
There is strong clinical suspicion of injury despite normal X-rays.
Plain X-rays are technically difficult or inadequate.
Plain X-rays identify a significant bony injury.

The scan should be performed within 1 hour of the risk factor being identified. A provisional
written radiology report should be made available within 1 hour of the scan being performed.

For information on sedation for imaging in children and young people see the NICE pathway on
sedation in children and young people.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

3. CT cervical spine scans

3 No risk factors but child has neck pain or tenderness

No additional information

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4 Risk factors indicating 3-view cervical spine X-rays within 1 hour

For children who have sustained a head injury and have neck pain or tenderness but no
indications for a CT cervical spine scan [See page 3], perform 3-view cervical spine X-rays
before assessing range of movement in the neck if either of these risk factors are identified:

Dangerous mechanism of injury; that is:

fall from a height of greater than 1 metre or 5 stairs
axial load to the head, for example, diving
high-speed motor vehicle collision
rollover motor accident
ejection from a motor vehicle
accident involving motorised recreational vehicles
bicycle collision.
Safe assessment of range of movement in the neck is not possible (see below).

The X-rays should be carried out within 1 hour of the risk factor being identified and reviewed by
a clinician trained in their interpretation within 1 hour of being performed.

Safely assessing range of movement in the neck

Be aware that in adults and children who have sustained a head injury and in whom there is
clinical suspicion of cervical spine injury, range of movement in the neck can be assessed safely
before imaging only if there are no high-risk factors for cervical spine X-rays (see above) or
scans [See page 3] and at least one of the following low-risk features apply. The patient:

was involved in a simple rear-end motor vehicle collision

is comfortable in a sitting position in the emergency department
has been ambulatory at any time since injury
has no midline cervical spine tenderness
presents with delayed onset of neck pain.

For information on sedation for imaging in children and young people see the NICE pathway on
sedation in children and young people.

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5 If safe assessment of neck movement is possible, can patient actively

rotate their neck to 45 degrees to the left and right?

No additional information

6 Perform 3-view cervical spine X-rays within 1 hour

If range of neck movement can be assessed safely in a child who has sustained a head injury
and has neck pain or tenderness but no indications for a CT cervical spine scan [See page 3],
perform 3-view cervical spine X-rays if the child cannot actively rotate their neck 45 degrees to
the left and right. The X-rays should be carried out within 1 hour of this being identified and
reviewed by a clinician trained in their interpretation within 1 hour of being performed.

For information on sedation for imaging in children and young people see the NICE pathway on
sedation in children and young people.

7 No imaging needed

No additional information

8 Return to assessment path

See head injury / assessment in the emergency department for patients with head injury

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Glasgow coma score

Base monitoring and exchange of information about individual patients on the three separate
responses on the GCS (for example, a patient scoring 13 based on scores of 4 on eye-opening,
4 on verbal response and 5 on motor response should be communicated as E4, V4, M5).

If a total score is recorded or communicated, base it on a sum of 15, and to avoid confusion
specify this denominator (for example, 13/15).

Describe the individual components of the GCS in all communications and every note and
ensure that they always accompany the total score.

In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to
facilitate scoring in preverbal children.

In some patients (for example, patients with dementia, underlying chronic neurological disorders
or learning disabilities) the pre-injury baseline GCS may be less than 15. Establish this where
possible, and take it into account during assessment.

Focal neurological deficit

problems restricted to a particular part of the body or a particular activity, for example, difficulties
with understanding, speaking, reading or writing; decreased sensation; loss of balance; general
weakness; visual changes; abnormal reflexes; and problems walking

High-energy head injury

for example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a
height of greater than 1 metre or more than 5 stairs, diving accident, high-speed motor vehicle
collision, rollover motor accident, accident involving motorised recreational vehicles, bicycle
collision, or any other potentially high-energy mechanism

Skull fracture or penetrating head injury

signs include clear fluid running from the ears or nose, black eye with no associated damage
around the eyes, bleeding from one or both ears, bruising behind one or both ears, penetrating
injury signs, visible trauma to the scalp or skull of concern to the professional

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Sources

Head injury: assessment and early management (2014) NICE guideline CG176

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Copyright

Copyright © National Institute for Health and Care Excellence 2016. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.

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